Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 25-year-old Caucasian male (CM) came to the ER complaining of suicidal thoughts and depression. The patient attempted to inhale carbon monoxide by putting a bag over his head and breathing in tail pipe fumes. He patient passed out briefly and then woke up. The patient decided to come to the ED, got back in his car and drove to the ER. He feels somewhat agitated and is crying. He does admit to temporary loss of consciousness while trying to kill himself. The patient drank alcohol yesterday, and used marijuana this morning, as well cocaine yesterday.
Past medical history (PMH)
Depression with a prior suicide attempt 8 months ago. He was planning of jumping off a bridge but the police intervened. HIV positive.
Social history (SH)
Alcohol and drug use as noted above, smoker.
Review of systems (RoS)
The patient passed out briefly. He does have some difficulty concentrating now. He has a left-sided headache. No focal neurological weakness or deficits.
Vital signs: 36.7-130-20-168/78
WD/WN in NAD. He has some difficulty focusing at times but responds appropriately, AAO x 3. The rest of the exam is unremarkable.
What is the most likely diagnosis?
What laboratory tests would you suggest?
Tylenol and salicylate levels
Urine toxic screen
ABG demonstrates carboxyhemoglobin level of 27.
Smoking can increase the carboxyhemoglobin level but a value higher than 10 is significant for poisoning.
BMP and ABG in CO poisoning (click to enlarge the images).
What should you do next?
Arrange for hyperbaric treatment. St. Vincent Medical Center has the regional hyperbaric chamber for Cleveland, Ohio.
The pulmonologist on call for the hyperbaric chamber was informed. The hyperbaric team was also and a treatment plan with 3 diving sessions was arranged. The patient had a rupture of both tympanic membranes but otherwise all his complaints resolved. ABG showed a return to normal values.
He was discharged to a psychiatric unit. ID was called for HIV treatment.
Carbon monoxide poisoning with carboxyhemoglobin level of 27.
What did we learn from this case?
The hyperbaric chamber is the treatment of choice for CO poisoning.
Common situations in which CO poisoning may occur are:
- Suicide attempt, e.g. breathing automobile exhaust fumes
- Falling asleep in the car in the garage while the engine is running
- Home gas system which is not working properly (that is why every house needs to have a CO detector)
- Boater operating a marine engine in a closed compartment when the wind is blowing from the back. Marine engines deliver a lot of CO in their exhaust fumes. Not surprisingly many accidental deaths on board are not due to drinking and falling over board but to CO poisoning.
Actions need to be taken to warn all on board about the CO danger and to decrease the emission of CO from the marine engines.
Suicide is second to only accidental death as the leading cause of mortality in young men across the world. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia (Lancet, 2012).
The Regional hyperbaric chamber for Cleveland, Ohio at St. Vincent Charity Hospital.
Hyperbaric Oxygen Therapy in eMedicine
Hyperbaric Facilities in Ohio - scuba-doc.com
Carbon Monoxide Poisoning. Lindell K. Weaver, M.D. NEJM, Volume 360:1217-1225 March 19, 2009 Number 12.
Miner's wife: 'He's strong enough to pull through' - CNN 01/2006.
Close Call. Fat Doctor, 04/2007.
How NOT to Heat Your Home This Winter. Emergency Physicians Monthly, 01/2009.